radial head fracture

1. RADIAL HEAD
FRACTURE
Dr krunal h patel

2. EPIDEMIOLOGY
 OF 4%OF ALL FRACTURE AND 30%OF ALL ELBOW FRACTURE.
 1/3 PT ASSOCIATED INJURY TO SHOULDER,HUMERUS,FOREARM,WRIST
OR HAND.
 RARE IN CHILDREN DUE TO CARTILAGENOUS NATURE OF RADIAL HEAD.
 RADIAL NECK FRACTURE MORE COMMON IN CHILDREN.

3. ANATOMY OF PROXIMAL RADIUS
RADIOCAPITELLAR JOINT TRANSMIT 50-60% LOAD ACROSS ELBOW

4. RADIUS HEAD SURGICAL ANATOMY
 IMPORTANT FOR
 VALGUS STABILITY
 POSTEROLATERAL ROTATORY STABILITY
 LONGITUDINAL FOREARM STABILITY
 (ALONG WITH INTEROSSI MEMBRANE & DRUJ)

5. ELBOW STABILITY
MCL & U-H JOINT:PRIARY STABILIZER
RADIAL HEAD(R-C JOINT) & CAPSULE:SECONDARY STABILIZER

6. CONT..

7. MUSCLE ATTACHMENT AROUND PROXIMAL RADIUS
 SUPINATOR ATTACHMENT AT PROXIMAL RADIUS.
 BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

8. POST.INTEROSSI NERVE AT RISK
 PIN TRAVERSES FROM ANTERIOR TO POSTERIOR THROUGH SUPINATOR MUSCLE.
 ALWAYS CHECK PRE OPERATIVE ACTIVE FINGER EXTENSION

9. MECHANISM OF INJURY
(1) FALL ON OUTSTRECHED HAND(MOST COMMON)
DISTAL RADIUS
INTEROSSI MEMBRANE(FOREARM)
RADIAL HEAD IMPACTION AGAINST CAPITELLUM
(2)VALGUS INJURY TO ELBOW/DIRECT INJURY
MCL RUPTURE/OLECRANON FRACTURE UNSTABLE ELBOW

10. DIAGNOSIS
 HISTORY:FALL ON OUTSTRETCHED HAND/DIRECT INJURY
 EXAMINATION:
 ELBOW
 SWELLING
 ECCHMOSIS
 ANCONEUS TRIANGLE FULLNESS
 RANGE OF MOTION RESTRICTION
 STABILITY
 ACTIVE FINGER EXTENSION
 FOREARM/INTEROSSI MEMBRANE TENDERNESS
 WRIST TENDERNESS
ESSEX LAPROSTI INJURY

11. X RAY FINDINGS
 STANDARD AP AND LATERAL X RAY of elbow
 OBLIQUE(GREEN SPAN)VIEW
 FOREARM AND WRIST X RAY IF REQUIRED

12. X RAY FINDINGS

13. CLASSIFICATION OF RADIAL HEAD FRACTURE
Mason classification
Type I
Minimally displaced fx, no mechanical
blockto rotation, intra-articular displacement
<2mm
Type II
Displaced fx >2mm or angulated, possible
mechanical block to forearm rotation
Type III
Comminuted and displaced fx, mechanical
block to motion
Type IV
(Hotchkiss/JOHNSTO
N modification OF
TYPE 3)
Radial head fracture with elbow dislocation
MORREY MODIFIED MASON CLASSIFICATION BY
QUANTIFYING DISPLACEMENT AREA >30% AND
DISPLACEMENT OF >2 MM

14. TREATMENT GOAL
 CORRECTION OF ANY BLOCK TO FOREARM ROTATION
 EARLY ROM OF ELBOW AND FOREARM
 STABILITY OF ELBOW AND FOREARM
 PREVENTION OF SECONDARY OSTEOARTHROSIS OF ELBOW

15. NON OPERATIVE TREATMENT
 INDICATION:
 ISOLATED RADIAL HEAD FRACTURE WITH MASON TYPE 1 (UNDISPLACED <2MM)
 PLASTER SLAB FOR 3 WEEKS
 EARLY ACTIVE MOBILIZATION OF ELBOW
 PERSISTANT PAIN.INFLAMMATION,CONTRACTURE SUSPECT CAPITELLAR
FRACTURE

16. OPERATIVE MANAGEMENT
OPEN REDUCTION & INTERNAL FIXATION
 INDICATION FOR ORIF:
 Mason type II with mechanical block(displaced)
 Large fragment >2 mm
 Mason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME)
 Mechanical block to motion (lignocaine inj in elbow joint)
 Presence of other complex ipsilateral elbow injuries(without metaphyseal bone
loss)
 FRAGMENT EXCISION LEADS TO INSTABILITY
 TRY TO PRESERVE SMALLEST FRAGMENT

17. Surgical approach for ORIF:
Kaplan direct lateral approach
 Interval between EDC and ECRB
 Keep forearm pronated to protect PIN
 PIN present approx. 2 cm below radial head
 Do not extend exposure below annular ligament
 Gentle retraction
 ADVANTAGE:
 No disruption LATERAL LIGAMENT COMPLEX(LUCL)
 DISADVANTAGE:
 PIN at risk

18. KOCHER POSTEROLATERAL APPROACH
 Interval between ECU and anconeus
 Keep forearm pronated to protect PIN
 Advantage:
 Less of a risk of PIN injury than the kaplan
 Disadvantage:
 LATERAL LIGAMENT COMPLEX may injured
 Leads to instability
 HOTCHKISS APPROACH
 DIRECTLY THROUGH EDC
 PROTECT LATERAL LIGAMENT COMPLEX

19.  PRONATE FOREARM WHILE FIXATION

20. SAFE ZONE OF RADIUS HEAD FIXATION
 LONGITUDINAL LINE B/W LISTER TUBERCLE AND RADIUS STYLOID PROCESS
 NO ARTICULATION WITH ULNA
 SAFE FOR IMPLANT INSERTION:NO IMPINGMENT IN ROTATION
POSTERO-LATERAL ZONE IN FULL SUPINATION(CAPUTO A)
IN NEUTRAL(MID PRONE)POSITION : ANTEROLATERAL ZONE

21. Which implant to use?
 Mini fragment screw(2.4 or 2.7 mm)(counter sink must)
 Headless compression compression screw/Herbert screw
 Low profile plate/mini t plate(in safe zone/postero lateral)
 K WIRE

22. COMPLICATION OF ORIF
 PIN INJURY
 HARDWARE FAILURE
 HARDWARE IMPINGEMENT
 STIFFNESS OF ELBOW
 RESTRICTION OF SUPINATIONPRONATION

23. RADIAL HEAD REPLACEMENT
 To prevent proximal migration of the radius
 Silicon implant poor outcome : SILICON SYNOVITIS
 Titanium/vitallium metallic implant of choice
 Indication:
 Extensive communition of radial head/excess bone loss
 Elbow instability:
 essex lapresti lesion,
 coronoid fracture,
 elbow dislocation,
 collateral ligament injury,
 olecranon fracture

24. RADIAL HEAD REPLACEMENT PROSTHESIS
 LOOSE STEMMED PROSTHESIS
 THAT ACTS AS A STIFF SPACER

25. BIPOLAR PROSTHESIS
 That is cemented into the neck of the radius
 COMPLICATIONS:
 Overstuffing of joint
 capitellar wear problems

 Malalignment instability

26. COMPLICATION OF REPLACEMENT
 Post operative infection of implant
 Ulnar nerve/pin injury
 Immediate post operative dislocation
 Recurrent instability
 Heterotrophic ossification
 Contracture /stiffness
 Crps type 1

27. RADIAL HEAD EXCISION
 INDICATION:
 Low demand, sedentary patients
 In a delayed setting for continued pain of an isolated radial head fracture
 CONTRAINDICATION:
 In children
 Presence of destabilizing injuries (Essex-lopresti lesion,fracture dislocation
elbow(mason type 4),monteggia)
 Terrible triad of elbow(coronoid fracture,MCL deficiency)

28. COMPLICATION OF EXCISION
 PROXIMAL MIGRATION OF RADIUS
 INFERIOR RADIO ULNAR JOINT DISTURBANCE
 PAIN & WEAKNESS OF WRIST
 Joint instability
 Decreased strength
 Cubitus valgus
 EXCESSIVE PROXIMAL MIGRATION REQUIRE RADIO ULNAR SYNOSTOSIS.

29. THANK YOU